A prospective study of microscope-integrated intraoperative fluorescein videoangiography during arteriovenous malformation surgery: preliminary results

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>The authors report on the use of a recently developed microscope-integrated fluorescent module using low-dose intravenous fluorescein for videoangiography during arteriovenous malformation (AVM) surgery.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>The authors analyzed the application of a low-dose intraoperative fluorescein in 4 consecutive patients undergoing AVM surgery. The ability to distinguish the associated vessels of the AVM from normal vessels and to assess the degree of AVM obliteration based on videoangiography of venous drainage was specifically analyzed.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>All 4 patients underwent fluorescein angiography without complication. In each case, videoangiography confirmed recognition of feeding arteries and draining veins through the operating oculars under the fluorescent mode. In one case involving a large frontal AVM, videoangiography demonstrated mainly cortical veins on the surface of the AVM and alerted the senior author to first tackle the feeding arteries in the interhemispheric space. While evaluating the flow within the different draining veins after most of the AVM was disconnected, videoangiography also prioritized the order for disconnection of large draining veins to allow mobilization the AVM and exposure of the remaining deep arterial feeders. In the other 3 cases, videoangiography allowed easy recognition of the angioarchitecture of the AVMs, estimated its cortical boundaries, and most importantly, assessed the flow within the draining veins before their disconnection.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>The authors found fluorescein videoangiography to be a useful adjunct in resection of AVMs. This technology offers the unique ability to visualize fluorescent vessels and nonfluorescent tissues in near-natural colors simultaneously and permits microsurgical manipulation of relevant structures under the fluorescent mode. Largerscale studies are needed to establish its efficacy and wider applicability.</jats:p></jats:sec>

Application of Indocyanine Green During Arteriovenous Malformation Surgery: Evidence, Techniques, and Practical Pearls

“…Post-resection FLOW 800 analysis demonstrates that the primary vein is now blue (D). Our team has also used fluorescein in place of the ICG and has found reasonable results similar to those of the ICG (41,42). The advantage of fluorescein over ICG is that the dye can be visualized through the microscope's binoculars (Figure 2) (43).…”

Application of Fluorescein Fluorescence in Vascular Neurosurgery

“…The arterial phase appears early when used in a patient with an abnormal connection between the venous and arterial circulations, such as a DAVF or AVM, where the blood flow is aberrantly fast. The arterial phase was reported to be 11 s in a case report of a DAVF (34) and 10–15 s in AVM surgeries (13, 16, 18, 23) after IV FNa injection. These durations are shorter than those reported during IV FNa videoangiography in aneurysm surgeries, in which the arterial phase typically appears for more than 20 s (20, 22, 31, 32).…”

“…Wrobel et al (32) reported a case of high-dose FNa videoangiography using 2,000 mg IV bolus. In other neurosurgical reports, IV doses range from 75 mg to 500 mg per bolus (6, 18–21, 30, 31, 33) or from 1 mg/kg to 1.5 mg/kg per body weight (16, 34).…”

Optical technologies for intraoperative neurosurgical guidance

“…Wide-field fluorescence imaging has the advantage of improved field of view with immediate visual feedback to the surgeon, which has exploited such fluorophores as PpIX, 32,33,96,102,116,127,130–133,136,148,153–156 ICG, 29,44,63,85 and fluorescein. 1,22,23,65,71,74–76,92,98,111,112,124,125,128 For example, ALA-PpIX fluorescence provides the surgeon with immediate visualization of a tumor, noting areas with significant PpIX accumulation as a red-pink fluorescence and areas without significant visible levels of fluorescence with a violet-blue background from the excitation light. Current PpIX microscope-based work in mostly high-grade gliomas report sensitivities as low as 20%–30%, specificities > 90%, and overall accuracies 70%–90%.…”